So said some of the newspaper headlines about the July 9 Archives of Internal Medicine paper, “Electronic Health Record Use and the Quality of Ambulatory Care in the United States.”

When I read the news coverage emanating from the study, it caught me — and I suppose many of you readers — off guard. I’m not one to bash the mass media, but reporters got this latest study on electronic health records and outcomes wrong. Journalists need a quick course in statistics, and perhaps simple reading mastery, to know the difference between causality and simple association.

A highly credible and switched-on team from Harvard and Stanford universities wrote the study, which the Agency for Healthcare Research and Quality funded. For the study, researchers studied data from the 2003 and 2004 National Ambulatory Medical Care Survey published by CDC. The data set detailed EHR use coupled with 17 ambulatory care quality indicators. These indicators covered medical management of common diseases, antibiotic prescribing, preventive counseling, screening tests and other services. According to the analysis, physicians’ performance on these quality indicators was not associated with the “use” of an EHR system.

All you have to do is read the second sentence in the paper abstract’s background paragraph to realize that the researchers were assessing “the association between EHR use, as implemented, and the quality of ambulatory care in a nationally representative survey.” Herein lies the nuance of the study: the authors did not seek to address whether the installation of an EHR would result in better outcomes, as newspapers incorrectly interpreted. They simply sought an association between EHRs and quality of care — and that they did not find.

It’s also important to closely look at the second half of that introductory sentence: the simple phrase, “EHR use, as implemented” (emphasis added). That is the point.

So, before you swallow the mass media line of reasoning that “EHRs don’t work,” take a few minutes to understand what’s really in the study.

A report detailing how the use of electronic health records does not necessarily lead to an increase in the quality of care may be misinterpreted by some as proof that EHRs aren’t useful. EHR vendors, consequently, are concerned.

“It’s caused quite a bit of discussion in our industry—to say the least,” said Hugh Zettel, director of government and industry relations for GE Healthcare. “We don’t believe the reporting on it has been accurate relative to the findings of that paper.”

The report, Electronic Health Record Use and the Quality of Ambulatory Care in the United States, appeared in the July 9 edition of the Archives of Internal Medicine, and concluded quite bluntly that: “As implemented, EHRs were not associated with better quality ambulatory care.”

Written by prominent health information technology figures from Harvard Medical School and Stanford University, the study examined records of 50,574 patient visits collected as part of the National Ambulatory Medical Care Survey in 2003 and 2004, and compared how physicians with and without EHRs did on 17 quality measures. The researchers concluded that EHR-using physicians had significantly better scores on only two quality indicators, had no significant difference on 14, and did significantly worse performance on one.

“The result was surprising,” said the study’s lead author, Jeffrey Linder, an assistant professor of medicine at Harvard Medical School and an internist at 746-bed Brigham and Women’s Hospital, Boston. “I was expecting to find that it (EHR use) was associated with better care.”

Linder said that most EHR quality studies have been done at what he described as “benchmark” institutions, and the intent of this study—which was sponsored by the Agency for Healthcare Research and Quality—was to take a more general view of how EHRs were being used across the nation. What the study shows, Linder said, is that with the way EHRs are being used they “are not much more than a replacement for the paper chart.”

“They’re not magic,” Linder said. “You just can’t plug it in, turn it on and watch quality magically improve.”

The two measures that the EHR-using physicians scored significantly better involved avoiding prescribing benzodiazepine to patients with depression and avoiding unwarranted urinalysis testing. The authors were surprised to report that EHRs were associated with worse quality when it came to prescribing statins to treat hyperlipidemia, or high cholesterol.

Linder said that he spent two days in vain trying to figure out that result. “It could be just statistical chance … it could be a statistical anomaly,” he said. “I don’t have a good explanation.”

Zettel disputed some of the findings, saying that GE Healthcare’s own research found that its customers had scores twice as high as those the researchers found on quality indicators relating to aspirin, beta blocker and statin prescribing. “We have a process that allows our customers to show these and other related metrics,” he said.

Mostly, however, Zettel said the findings may be a reflection of when half the data were collected: 2003.

“A lot has changed since then,” he said, and this includes an evolving definition of “EHR.”

According to the report, about 16% of the visits studied from 2003 involved EHRs, as did 20% of the visits in 2004.

Another of the study’s co-authors, Randall Stafford, an associate professor of medicine at Stanford University’s Prevention Research Center, acknowledged Zettel’s arguments, but said the findings point to the need for multidimensional solutions to confront the complex problems relating to healthcare quality. These include a need to look at how healthcare is organized and paid for and how continuity of care is provided for chronic conditions, he said.

“The bottom line is that people have to pay attention to more than just the EHR and to think that the electronic health record will improve quality on its own is ridiculous,” Stafford said. “The electronic health record in and of itself is not going to be adequate.”

Additionally, the report states that “it is worth noting that the performance on most indicators was suboptimal regardless of whether an EHR was used.”

Zettel somewhat agreed with Stafford’s assessment.

“There’s that old axiom that a fool with a tool is still a fool,” he said. “And, if you don’t change your processes, (implementing technology) will just help you make the same mistakes faster and more efficiently.”

Electronic health record systems in less than two years after adoption can create enough cost reductions to pay for the cost of the systems, according to a study published in the July issue of the Journal of the American College of Surgeons, HealthDay News/Forbes reports.

David Krusch, the author of the study, and his colleagues at the University of Rochester analyzed the return on investment of EHR systems at five ambulatory offices representing 28 health care providers. The study compared the costs of tasks — such as pulling patient charts, creating new charts, filling time, support staff salary and data transcription — in the third quarter of 2005 to costs in Q3 2003 when the EHR system was not instituted.

Using EHRs reduced costs by almost $394,000 annually, and nearly two-thirds of the savings were associated with reducing the amount of time for manually pulling charts, the study found. The EHR system in the first year cost $484,577 to install and manage, which means the hospital recouped its investment in the system within the first 16 months.

The system after the first year cost about $114,000 annually to operate, which means a yearly savings of more than $279,500, or almost $10,000 per provider using the system, the researchers found.

“Health care providers most frequently cite cost as a primary obstacle to adopting an [EHR] system. And, until this point, evidence supporting a positive return on investment for [EHR] technologies has been largely anecdotal,” Krusch said (HealthDay News/Forbes, 7/12).

The American Health Information Community Consumer Empowerment Workgroup on Wednesday said they would continue to study the policy issues related to secondary use of health care information, Healthcare IT Newsreports.

Karen Bell, director of HHS’ Office of IT Adoption, said now is the time to tackle the issue because electronic health record adoption still is low and personal health records do not yet contain much clinical information. “I think we are recognizing that we’re not even close to finding all the answers on this,” Bell said.

Charles Safran of Harvard Medical School testified before the work group on secondary uses of health data. “We believe there is tremendous value in secondary use of health information,” he said, adding, “It’s so important to national health, but we need to have better guidelines on how this information should flow.”

Guaranteeing the privacy of health data is key to winning public trust, and the technology has outpaced policies and procedures so far, Safran said. He added, “The public is woefully unaware to what is happening to their data.”

July 13, 2007 iHealthbeat

Nancy Davenport-Ennis, co-chair of the work group and executive director of the National Patient Advocate Foundation, said the group initially will focus on determining who owns the data. She added that the group should look into how to regulate a violation of stewardship over the data, how to protect consumers and how to provide incentives to consumers who make lifestyle chances based on the data collected.

In addition, the Agency for Healthcare Research and Quality recently requested information on the idea of national stewardship over the secondary use of data (Manos, Healthcare IT News, 7/12).

Experts speaking at the American Medical Association’s annual House of Delegates meeting agreed that widespread adoption of electronic medical records is inevitable, but—during a symposium entitled Health Information Technology: Is It Help or Hype?—there was disagreement on the best way to wean a medical practice off its paper record system.

In her PowerPoint presentation, Barbara McAneny, an oncologist and chief executive officer of the New Mexico Cancer Center, Albuquerque, showed the 200 or so physicians in the audience a slide reading “Scan everything!!!” and then she recalled how her organization “hired every college kid in Albuquerque” to scan old paper charts into the new electronic system.

“It is expensive and it is necessary,” she said. “And all this has to occur before you let the physicians get near the system.”

A few weeks after everything is scanned and the EMR system is up and running, McAneny recommends shredding the paper records. “There is no going back,” she warned, adding that the old file space at her organization is now being used as clinical space.

McAneny said that, as long as the paper-based system exists, there will be people on staff tempted to use it.

“The temptation is to run two systems and my advice is: Don’t do it,” she said. “You won’t get the implementation you want.”

But Philip Tally, a Bradenton, Fla., neurosurgeon who has been using health IT and developing software for 15 years, said that his organization took about three years to transition over to an entirely electronic system. He said it wasn’t necessary to scan everything because, what they found they really needed were the most recent hospital discharge summaries and prescription records.

“We’d pull out practical things we needed to know and scanned those,” he said.

McAneny, however, said that she still found 20-year-old pathology reports useful in her oncology practice and she was convinced that scanning everything was the way to proceed.

Another speaker, family physician Bernd Wollschlaeger showed a picture of his North Miami Beach, Fla., office which was devoid of filing cabinets.

“I have no paper records in my office,” Wollschlaeger said, noting that scheduling for his cash-only practice is all done online.

He also said that, while he was waiting for his turn to speak, he used his personal computer to refill prescriptions and process appointment requests, and he explained that EMRs help physicians know what they’re doing with their practice.

“This is not just a platitude,” he said. “This gives me tremendous professional satisfaction—and it makes me money.”

When speaking to IT vendors, Wollschlaeger recommended that physicians describe their typical patient and then ask the vendor how its product will help with that patient.

“If they say ‘I’ll get back to you,’ they’re gone,” he said. “They need to be able to answer your basic questions.”

All three speakers agreed that electronic records would become the norm, and Tally cited a study on consumer preferences for maintaining personal health records. According to Tally, 28% of those surveyed would prefer to store the records on a smart card, 27% prefer online storage, 21% wanted to use a flash drive, and 24% still preferred to keep records on paper.

“If you’re one of those who still believe in paper,” Tally said, “you better seek out that 24%.”

Analysts-Microsoft-Google-Could-Prompt-Disruptive-Change.aspxRecognizing that many Internet searches are related to health care, Google and Microsoft are working to build a presence in the health care industry, Government Technology reports. The move could significantly impact health care professionals and medical device manufacturers, according the Wireless Healthcare, an analyst group in the United Kingdom.

Google’s recent investment in the genetic profiling company 23andMe and Microsoft’s purchase of the medical search company Medstory could result in new services that are disruptive to the industry, according to Wireless Healthcare.

“We are seeing the emergence of a new e-health model that challenges some the assumptions made by existing online health care providers and medical device manufacturers,” Peter Kruger, an analyst with Wireless Healthcare, said. He added, “This new model impacts not only on how diseases are diagnosed but also the way health care is delivered and e-health services are funded.”

Kruger noted that Internet search engines currently profit mostly from advertising, which is unlikely to be the funding model used for online health. “Advertising and health care do not mix well and this issue is already proving to be controversial,” he said, adding, “I am sure that regulators would be unhappy if banner advertisements started to appear on a patient’s online medical record or diagnosis.”

Wireless Healthcare in a report details a number of funding models already used by companies marketing health care devices and services to the growing demographic of consumers ages 40 to 59 years old. Kruger in September will present research on new models for online health care at a conference in San Francisco (Government Technology, 7/10).

Science Daily — STANFORD, Calif. — Electronic health records have been hailed as a key element in making U.S. medical care more effective and efficient, but a new study led by a researcher at the Stanford University School of Medicine shows that electronic records were not associated with improved quality of outpatient health care in 2003 and 2004.

Of 17 quality indicators assessed by the study, electronic health records made no difference in 14 measures. In two areas, better quality was associated with electronic records, while worse quality was found in one area.

Senior author Randall Stafford, MD, PhD, associate professor of medicine at the Stanford Prevention Research Center, said that given the overall mediocre performance of physicians in the 17 quality indicator areas, he and his colleagues had expected better quality from doctors using electronic records.

Stafford said the study doesn’t discount the value of electronic health records, but points out that the entire health-care system needs to embrace the concept of improving the quality of care delivered in clinic and office visits.

“We need to be cautious about the assumption that electronic health records are going to solve problems around health-care quality by themselves,” Stafford said. “It’s not sufficient to have an electronic health record system that provides readily available patient data and decision-making guidance. Physicians have to be receptive to that input and willing to act on that input.”

The study, produced by a team of researchers from the Stanford and Harvard medical schools, will be published in the July 9 issue of the Archives of Internal Medicine.

The 14 quality indicators for which electronic records made no significant difference included such factors as prescribing recommended antibiotics; diet and exercise counseling for high-risk adults; screening tests; and avoiding potentially inappropriate prescriptions for elderly patients.

In two quality areas – not prescribing benzodiazepine tranquilizers for patients with depression, and avoiding routine urinalysis during general medical exams – doctors using electronic record systems fared better than those who didn’t. But when it came to prescribing statins for patients with high cholesterol, physicians using electronic systems did worse.